Systems Plus College Foundation Balibago, Angeles City PampangaIn partial fulfillment of the Course requirements in Related Learning Experience Medical-Surgical Nursing 1stSemester A.Y. 2012-2013 Case Report “Appendectomy” Presented to Arnel Jay Sali, RM, RN, MSN Presented by Princess Hannah Kelly Gepte July 24, 2012
I. Introduction Surgery is an important technique used to diagnose or to treat illness or injury with the goal of restoring patients to an acceptable state of health, or for cases in which disease is nonrecoverable, to alleviate distress. Appendectomy is the most common emergent surgical procedure performed worldwide. It is a surgery to remove the appendix. There are two types of appendectomy, the “open appendectomy” and the “laparoscopic appendectomy”. Most appendectomies are now done laparoscopically, expect in cases where rupture is suspected. It is usually performed on people with appendicitis (inflammation of the vermiform appendix). The appendix is a small, finger-like shaped sac that attached to the cecum of the large intestine. If the appendix ruptures or perforates before surgery, its infected contents spill into the peritoneal cavity, possibly causing peritonitis. The perforation of the appendix is the most common and fatal complication of appendicitis, with a mortality rate of 10%. Appendicitis occurs in approximately 7% of the population and affects males more than females. It occurs more in the teenagers than adults and most commonly occurs between the ages of 10 and 30 years. Statistics in the Philippines shows that about 215,604 of the 86,241,697 Filipinos had an incident of appendicitis. According to the US national Library of Medicine National Institute of Health there is a new method of mini invasive surgery called Natural Orifice Transluminal Endoscopic Surgery it involves passing surgical instruments, and a tiny camera through a natural orifice, such as the mouth, vagina, urethra or rectum, provides the access to the desired organ. An operation called “Transvaginal Appendectomy” was performed in Caucasus- Academician N. Kipshidze University Hospital in Tbilisi. They performed it on two patients the first case was a 28-year old woman with 48 hours acute appendicitis and the second case was a 22- year old woman with 24 hours acute appendicitis. Both operations were performed under general anesthesia. The duration of the first procedure was 76 minutes and the second operation lasted for 88 minutes. The operations were made without any technical difficulties or complications. None of the patients had the need of non-narcotic analgesia during post- operational period, no gynecological or surgical problems or any complications were detected during observation period. The benefits of the procedure are less pain, quicker recoveries, fewer complications and no scar. It can also avoid major incisions through the
skin, muscle and nerves of the abdomen. They also considered the procedure to be themost safe and feasible for clinical application. As a nursing student we must know how the procedure is performed, it isimportant to know your role and responsibility in the operating room, to know what might methe complications that may occur during the procedure. (http://www.ncbi.nlm.nih.gov/pubmed/19359710Tabutsadze T, Kipshidze N. Academician N. Kipshidze Central University Hospital, Tbilisi, Georgia, 2009 Contemporary Medical-Surgical Nursing 2nd Edition 2012 by Rick Daniels and Leslie Nicoll)
II. The Surgical procedure A. Description of the Procedure Appendectomy is a surgical procedure for patients diagnosed of appendicitis to remove inflamed appendix. A common emergency surgery, an appendectomy aims to prevent rupture or perforation of the appendix. The appendix sometimes gets blocked and becomes infected and swollen. Signs of an infected appendix include abdominal pain in the lower right side, fever, poor appetite, nausea and vomiting. If the appendix bursts, another complications will occur. Appendectomy is usually performed before these complications occur, an appendectomy is usually effective. If the appendix ruptures or perforates before surgery, its infected contents spill into the peritoneal cavity, possible causing peritonitis. This is the most common and fatal complications of appendicitis. There are two ways to do this surgery: • Open appendectomy – a single incision is made in the abdomen. The doctor works through this larger incision to remove the appendix. The surgeon makes an incision about 2 to 4 inches long in the lower right side of the abdomen and cuts through fat and muscle layers to the appendix. The appendix is removed from the intestine. The area is washed with sterile fluid to decrease the risk of further infection. A small drainage tube may be placed going from the inside to the outside of the abdomen. The drain is usually removed in the hospital. The site is closed with sutures or staples or covered with glue-like bandage and steri-strips.
• Laparoscopic appendectomy - 3 or 4 small incisions are made in the abdomen. The doctor uses a camera and tools through the small incisions to remove the appendix. A port (nozzle) is inserted into one of the slits, and carbon dioxide gas inflates the abdomen. This process allows the surgeon to see the appendix more easily. A laparoscope is inserted through another port. It looks like a telescope with a light and camera on the end so the surgeon can see inside the abdomen. Surgical instruments are placed in the other small openings and used to remove the appendix. The area is washed with sterile fluid to decrease the risk of further infection. The carbon dioxide comes out through the slits, and then the sites are closed with sutures or staples or covered with glue-like bandage and steri-strips.With this type of surgery, you may recover faster, have less pain, less scarring, fewer wound problems and often spends less time in the hospital.• Non surgical - If you only have some of the signs of appendicitis, your surgeon may monitor you to see if the symptoms get any worse. If you have an abscess (a collection of pus), your surgeon may treat you with antibiotics first and may have you come back for elective surgery in 4 to 6 weeks.
B. Indications Appendicitis - Is the inflammation of a narrow, blind protrusion called the vermiform appendix located at the tip of the cecum in the right lower quadrant of the abdomen. - The most common cause of acute surgical abdomen. Although it can occur at any age, it more commonly occurs between the ages of 10 to 30 years.The patient with appendicitis has relatively predictable clinical manifestations. o There is periumbilical pain that may initially be vague and generally spread over the lower abdominal region. Later, the pain localizes in the RLQ at Mcburney’s point. The pain is worse when manual pressure near the region is suddenly released. o Low-grade fever. o It may also be possible to elicit Rovsing’s sign. o Reduced appetite (anorexia) o Nausea; vomitingClassifications of Appendicitis 1. Simple – Appendix is inflamed but is still intact. 2. Gangrenous –There is tissue necrosis and microscopic areas of perforation. 3. Perforation –There is large perforation, which involves contents flowing into the peritoneal cavity.
C. Instruments Needed The Appendectomy Surgery instrument set includes:01 Metzenbaum Scissors 20cm TCCurved01 Metzenbaum Scissors 20cm TCStraight01 Mayo Scissors14cm Curved TC01 Mayo Scissors 14cm Straight TC02 Scalpel Handle # 402 Allis Tissue Forceps 15cm04 Kochers Tissue Forceps 1:201 Mcindoe Forceps 15cm02 Babcocks Tissue Forceps 16cm02 Mayo Hegar Needle Holder 16cm02 Sponge Holding Forceps04 Backhaus Towel Clamps 11cm08 Criles Forceps14cm curved06 Criles Forceps14cm Straight06 Spencer Wells Straight 18cm08 Spencer Wells Curved 18cm02 U S Army Retractor 21cm02 Adson Forceps 12cm02 Adson Forceps 1:2 12cm02 Lane Forceps 1:2 18cm02 Forceps 16cm04 Gallipots02 Kidney Dish 8"
Instruments for Laparoscopy Insufflator Veress needle Laparoscope 5mm claw grasper 5mm dolphin-nose grasper Endo GIA™ 30 with cartridges (white/blue) D. Perioperative ResponsibilitiesPreoperative management • All diagnostic tests and procedures are explained to promote cooperation and relaxation. • The patient is prepared for the type of surgical procedures as well as the post operative care. • Measures to prevent postoperative complication are taught, including coughing, turning, and deep breathing using splint at the incision site. • I.V fluids or total parenteral nutrition before surgery maybe ordered to improved fluid and electrolyte balance and nutritional status. • Intake and output is monitored. • Preoperative laboratory are obtained. • Bowel cleansing will be initiated 1 to 2 days before surgery for better visualization. • Antibiotics are ordered to decrease the bacterial growth in the colon. • Patient may not have anything by mouth after midnight the night before surgery. Medication may be withheld, if ordered. This will keep the GI tract clear.
Intraoperative Management • Position the patient on the OR table • Skin preparation • Induction of anesthesia • Procedures done aseptically • Closing of the incision • Dressing of the sitePostoperative Management • Monitor vital signs for sign of infection and shock such as fever, hypotension and tachycardia. • Monitor I and O for sign of imbalance, dehydration, and shock. • Assess abdomen for increased pain, distention, rigidity, and rebound tenderness because these may indicate postoperative complications. • Evaluate dressing and incision. • Evaluate the passing of flatus or feces • Monitor for nausea and vomiting. • Laboratory values are monitored and patient is evaluated for sign and symptoms of electrolyte imbalances. • Wound drains, I.V, and all other catheter are monitored and evaluated for signs of infections. • Turning, coughing, deep breathing and incentive spirometry is performed every 2 hours. • Diet is advanced as ordered. • Administration of medications as ordered • Patient Education and Health Maintenance • Instruct patient to avoid heavy lifting for 4 to 6 weeks after surgery. • Instruct patient to report symptoms of anorexia, nausea, vomiting, fever, abdominal pain, incisional redness and drainage postoperatively. • Teach patient and family to care for the wound and perform dressing changes and irrigations as prescribed. • Reinforce need for follow-up appointment with surgeon. E. General Effects of the procedure on the patient - As we all know the appendix is part of the human immune system. A client who undergoes appendectomy appears to cause no change in digestive function or overall lifestyle, and living without the appendix does not cause any problems regarding in our health.
a. Medical Management 1. Ceftriaxone – Bactericidal/Antibiotic • Perioperative Prophylaxis 2. Tramadol – Analgesic • Relief of moderate to severe pain 3. Ketorolac – NSAIDs • Short term management of pain 4. Cefotiam Hydrochloride - Antibiotic • Prophylaxis for surgical infection, postoperative infectionsIII. Conclusion The surgical journey begins when the patient first becomes aware of the need for surgery and ends when the patient is well enough to go home or to an intermediate care facility. I have learned that the perioperative experience may be one if the most tension periods of hospitalization. It is important to know your responsibilities. For the patient this is the period where they are vulnerable and very afraid. I have also learned that the duty of a scrub nurse is working directly with the surgeon within the sterile filed, passing instruments and other things needed during the operation, and always maintain sterility. The duty of the circulating nurse are done outside the sterile field, he/she counts the instruments that was used, the nurse must have a critical thinking skills, as he/she observes the operation and assist the surgical team to provide a safe and comfortable environment. I have also learned in this case report the responsibilities of the nurse during appendectomy, the types of surgery, the purpose of the appendix in our body, the risk and complications of appendicitis and how the procedure is performed. References: https://www.healthinfotranslations.org/pdfDocs/Appendectomy.pdf 2008 http://www.surgeons.org.uk/general-surgery-operation-howto/open-appendicectomy.html 2010 http://www.medical-tools.com/shop/appendectomy-set.html Medical-Surgical Nursing by Wolters Kluwer| Lippincott Williams & Wilkins 2008 2nd Edition
Medical-Surgical Nursing Volume 2 Sixth Edition 2010 by Ignatavicius and WorkmanContemporary Medical-Surgical Nursing 2nd Edition 2012 by Rick Daniels and Leslie NicollIntroductory Medical-Surgical Nursing Ninth Edition 2007 by Barbara K. Timby and Nancy E.Smithhttp://www.umm.edu/patiented/articles/appendectomy_normal_anatomy_000104_1.htm 2009http://www.scribd.com/doc/28298226/Appendicitis-Appendectomy-ppt 2010http://www.webmd.com/digestive-disorders/picture-of-the-appendix 2008Contemporary Medical-Surgical Nursing 2007 by Rick Daniels, Laura Nosek and Leslie Nicoll